Voluntary Life Insurance with Accidental Death and Dismemberment (AD&D) SUMMARY OF BENEFITS

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1 Voluntary Life Insurance with Accidental Death and Dismemberment (AD&D) SUMMARY OF BENEFITS Sponsored by: Clarksville-Montgomery County Employees Life Benefit Employee Spouse Dependent Amount Choice of $10,000 increments. Not to exceed 5 times your annual salary. Employees age 70 and older, maximum benefit is $30,000. Choice of $5,000 increments Employee must elect coverage for spouse to be eligible. Not to exceed 50% of employee elected amount. Minimum Amount $10,000 $5,000 $10,000 Maximum Amount $500,000 $250,000 $10,000 Guarantee Issue $200,000 under age 60 $10,000 age No Guarantee Issue age 70 and older AD&D Benefit Employee Spouse Amount Benefit Reduction Employee Benefits will reduce: Additional Benefits The benefit amount is equal to the life amount elected by you. Cost included in the schedule. At Age 70-Benefits will reduce to the lesser of one times basic annual earnings or $30,000, whichever is less Benefits terminate at retirement Accelerated Death Benefit Portability Conversion $100,000 under employee age 60 No Guarantee Issue employee age 60 and older Same as employee Spouse Eligibility Employee Spouse and Dependents All full-time active employees working 15 or more hours per week in an eligible class are eligible for coverage. A delayed effective date will apply if the employee is not actively at work. $250 Child: 14 days to 6 months $10,000 Child: 6 months to age 19 (to age 25 if full-time student) Newborn children to age 14 days are not eligible for a benefit. $10,000 At Employees Age 70-Benefits will reduce to the lesser of one times basic annual earnings or $30,000, whichever is less Benefits terminate at employee retirement Cannot be in a period of limited activity on the day coverage takes effect.

2 Clarksville-Montgomery County Employees Employee Premium Life with Accidental Death and Dismemberment Premium for sample benefit amounts Rates are based on 10 pay periods per year Employee and Spouse Premiums are calculated separately. Spouse premiums will be calculated based on employee age. Refer to Program Specifications for your maximum benefit amounts. Benefits and premium amounts reflect age reductions. AGE Rate per $1,000 $10,000 $20,000 $30,000 $40,000 $50,000 $60,000 $70,000 $80,000 $90,000 $100,000 < $1.44 $2.88 $4.32 $5.76 $7.20 $8.64 $10.08 $11.52 $12.96 $ $1.56 $3.12 $4.68 $6.24 $7.80 $9.36 $10.92 $12.48 $14.04 $ $1.92 $3.84 $5.76 $7.68 $9.60 $11.52 $13.44 $15.36 $17.28 $ $2.76 $5.52 $8.28 $11.04 $13.80 $16.56 $19.32 $22.08 $24.84 $ $4.20 $8.40 $12.60 $16.80 $21.00 $25.20 $29.40 $33.60 $37.80 $ $6.00 $12.00 $18.00 $24.00 $30.00 $36.00 $42.00 $48.00 $54.00 $ $8.64 $17.28 $25.92 $34.56 $43.20 $51.84 $60.48 $69.12 $77.76 $ $13.80 $27.60 $41.40 $55.20 $69.00 $82.80 $96.60 $ $ $ $24.48 $48.96 $73.44 $97.92 $ $ $ $ $ $ $34.32 $68.64 $ N/A N/A N/A N/A N/A N/A N/A $73.44 $ $ N/A N/A N/A N/A N/A N/A N/A This is an estimate of premium cost. Actual deductions may vary slightly due to rounding and payroll frequency. Example: Use this formula to calculate premium for benefit amounts over $100,000. Age Rate Per $1,000 X Benefit In $1,000 s = Cost Example: X 120 = $23.04 Dependent Children Rate = $2.40 per Pay Period X = Premium covers all dependent children regardless of the number of children.

3 Clarksville-Montgomery County Employees Spouse Premium Life with Accidental Death and Dismemberment Premium for sample benefit amounts Rates are based on 10 pay periods per year Employee and Spouse premiums are calculated separately. Spouse premiums will be calculated based on the Employee s age. Refer to Program Specifications for your maximum benefit amounts. Benefits and premium amounts reflect age reductions. AGE Rate per $1,000 $5,000 $10,000 $15,000 $20,000 $25,000 $30,000 $35,000 $40,000 $45,000 $50,000 < $0.72 $1.44 $2.16 $2.88 $3.60 $4.32 $5.04 $5.76 $6.48 $ $0.78 $1.56 $2.34 $3.12 $3.90 $4.68 $5.46 $6.24 $7.02 $ $0.96 $1.92 $2.88 $3.84 $4.80 $5.76 $6.72 $7.68 $8.64 $ $1.38 $2.76 $4.14 $5.52 $6.90 $8.28 $9.66 $11.04 $12.42 $ $2.10 $4.20 $6.30 $8.40 $10.50 $12.60 $14.70 $16.80 $18.90 $ $3.00 $6.00 $9.00 $12.00 $15.00 $18.00 $21.00 $24.00 $27.00 $ $4.32 $8.64 $12.96 $17.28 $21.60 $25.92 $30.24 $34.56 $38.88 $ $6.90 $13.80 $20.70 $27.60 $34.50 $41.40 $48.30 $55.20 $62.10 $ $12.24 $24.48 $36.72 $48.96 $61.20 $73.44 $85.68 $97.92 $ $ $17.16 $34.32 $51.48 $68.64 $85.80 $ N/A N/A N/A N/A $36.72 $73.44 $ $ $ $ N/A N/A N/A N/A This is an estimate of premium cost. Actual deductions may vary slightly due to rounding and payroll frequency. Example: Use this formula to calculate premium for benefit amounts over $50,000. Age Rate Per $1,000 X Benefit In $1,000 s = Cost Example: X 95 = $18.24 Dependent Children Rate = $2.40 per Pay Period X = Premium covers all dependent children regardless of the number of children.

4 Definitions Accelerated Death Benefit AD&D Conversion Guarantee Issue Term Life Exclusion: Suicide When diagnosed as terminally ill (having 12 months or less to live), you may withdraw up to 75% of your life insurance coverage to a maximum of $250,000. The death benefit will be reduced by the amount withdrawn. To qualify, you satisfied the Active Work rule and have been covered under this policy for at least 12 months. Check with your tax advisor or attorney before exercising this option. Accidental Death and Dismemberment (AD&D) insurance provides specified benefits for a covered accidental bodily injury that directly causes dismemberment (e.g., the loss of a hand, foot, or eye). In the event that death occurs from a covered accident, both the life and the AD&D benefit would be payable. If you terminate your employment or become ineligible for this coverage, you have the option to convert all or part of the amount of coverage in force to an individual life policy on the date of termination without Evidence of Insurability. Conversion election must be made within 31 days of your date of termination. For timely entrants enrolled within 31 days of becoming eligible, the Guarantee Issue amount is available without any Evidence of Insurability requirement. Evidence of Insurability will be required for any amounts above this, for late enrollees or increase in insurance and it will be provided at your own expense. Coverage provided to the designated beneficiary upon the death of the insured. Coverage is provided for the time period that you are eligible and premium is paid. There is no cash value associated with this product. Benefits will not be paid if the death results from suicide within two years after coverage is effective. May apply if employee contributes toward the premium. Additional Benefits BeneficiaryConnect SM TravelConnect SM Support services for beneficiaries who have experienced a loss. Travel assistance services for employees and eligible dependents traveling more than 100 miles from home. For assistance or additional information Contact Lincoln Financial Group at (800) or log on to NOTE: This is not intended as a complete description of the insurance coverage offered. Controlling provisions are provided in the policy, and this summary does not modify those provisions or the insurance in any way. This is not a binding contract. A certificate of coverage will be made available to you that describes the benefits in greater details. Should there be a difference between this summary and the contract, the contract will govern Lincoln National Corporation Group Insurance products are issued by The Lincoln National Life Insurance Company (Ft. Wayne, IN), which is not licensed and does not solicit business in New York. In New York, group insurance products are issued by Lincoln Life & Annuity Company of New York (Syracuse, NY). Both are Lincoln Financial Group companies. Product availability and/or features may vary by state. Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates. Each affiliate is solely responsible for its own financial and contractual obligations.

5 ENROLLMENT FORM FOR GROUP INSURANCE OPEN ENROLLMENT ONLY Please Use Ink or Type GROUP ID: GROUP POLICY #: CMBOARD A. Employee Information (Complete for ALL Enrollments) Employer Name/Company Name (Please Print) Clarksville-Montgomery County Employees Insurance Trust The Lincoln National Life Insurance Company P.O. Box 2616, Omaha, NE Phone: (800) Fax: (877) Billing Division or Location: County B.O.E Government County Employer ZIP State Employee Last Name First Name Middle Initial Social Security Number Date of Birth Spouse Last Name First Name Middle Initial Social Security Number Date of Birth Gender: Male Female Marital Status: Married Single Home Phone ( ) Completed By Employer Average Hours Worked Per Week: Occupation: Work Phone ( ) Earnings: Hourly Monthly Weekly Yearly $ B. Product Selection (Complete for ALL Enrollments) Voluntary Coverage NOTE: Please mark the box or boxes for each coverage you are applying for. All coverage amounts are subject to the limitations and exclusions as stated in the policy. CLASS TYPE OF COVERAGE AMOUNT OF COVERAGE TOTAL PREMIUM 03 Voluntary Employee Life/AD&D Insurance Yes No $ $ 03 Voluntary Spouse Life/AD&D Insurance Yes No $ $ 03 Voluntary Dependent Child Benefit Yes No $10,000 $ C. Beneficiary Information (Complete ONLY for Life or AD&D Enrollments) Primary Beneficiary's Last Name First MI Relationship of Beneficiary Social Security Number Contingent Beneficiary's Last Name First MI Relationship of Beneficiary Social Security Number Note: A Contingent Beneficiary will receive benefits only if the Primary Beneficiary does not survive you. If you wish to designate more than one Primary or Contingent Beneficiary, please attach a separate sheet of paper. E. Request for Coverages This coverage has been offered to me and after careful consideration of the benefits, I have decided to: REQUEST COVERAGE for which I am or may become eligible under the group policies issued by The Lincoln National Life Insurance Company. I hereby apply for group insurance, for which I am eligible or may become eligible. If contributions are required, I authorize my employer to deduct premiums from my salary. NOT ENROLL myself in the Program. I understand that if I apply for coverage at a later date, and if a physical examination or further medical information is required, it will be at my own expense. NOT ENROLL my dependents in the Program. I understand that if I apply for coverage for my dependents at a later date, and if a physical examination or further medical information is required, it will be at my own expense. NOTE: A PERSON COMMITS INSURANCE FRAUD, IF HE OR SHE SUBMITS AN APPLICATION OR CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT WITH INTENT TO DEFRAUD (OR KNOWING THAT HE OR SHE IS HELPING TO DEFRAUD) AN INSURANCE COMPANY. The insurance requested on this enrollment form will not be effective until approved by the Group Insurance Service Office of The Lincoln National Life Insurance Company, and the initial premium is paid to The Lincoln National Life Insurance Company. A delayed effective date will apply if the employee is not actively at work, or a dependent is in a period of limited activity on the date insurance would otherwise take effect. Employee Full Name: Employee Signature: Date: GLAD 4 11/00 Rev. 04/07 TN

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